Adherence to prescribed oral hypoglycaemic medication in a population of patients with Type 2 diabetes: a retrospective cohort study

[Geriatric aspects for the management of diabetes mellitus]

There is a high prevalence of diabetes mellitus in the elderly population of industrial countries. The present article provides recommendations for the screening, prevention and treatment of elderly diabetic patients according to current scientific evidence.

Should Studies of Diabetes Treatment Stratification Correct for Baseline HbA1c?

Aims

Baseline HbA1c is a major predictor of response to glucose lowering therapy and therefore a potential confounder in studies aiming to identify other predictors. However, baseline adjustment may introduce error if the association between baseline HbA1c and response is substantially due to measurement error and regression to the mean. We aimed to determine whether studies of predictors of response should adjust for baseline HbA1c.

Methods

We assessed the relationship between baseline HbA1c and glycaemic response in 257 participants treated with GLP-1R agonists and assessed whether it reflected measurement error and regression to the mean using duplicate ‘pre-baseline’ HbA1c measurements not included in the response variable. In this cohort and an additional 2659 participants treated with sulfonylureas we assessed the relationship between covariates associated with baseline HbA1c and treatment response with and without baseline adjustment, and with a bias correction using pre-baseline HbA1c to adjust for the effects of error in baseline HbA1c.

Results

Baseline HbA1c was a major predictor of response (R² = 0.19,β = -0.44,p<0.001).The association between pre-baseline and response was similar suggesting the greater response at higher baseline HbA1cs is not mainly due to measurement error and subsequent regression to the mean. In unadjusted analysis in both cohorts, factors associated with baseline HbA1c were associated with response, however these associations were weak or absent after adjustment for baseline HbA1c. Bias correction did not substantially alter associations.

Conclusions

Adjustment for the baseline HbA1c measurement is a simple and effective way to reduce bias in studies of predictors of response to glucose lowering therapy.

Novel mitochondrial complex I inhibitors restore glucose-handling abilities of high-fat fed mice

Metformin is the main drug of choice for treating type 2 diabetes, yet the therapeutic regimens and side effects of the compound are all undesirable and can lead to reduced compliance. The aim of this study was to elucidate the mechanism of action of two novel compounds which improved glucose handling and weight gain in mice on a high-fat diet. Wildtype C57Bl/6 male mice were fed on a high-fat diet and treated with novel, anti-diabetic compounds. Both compounds restored the glucose handling ability of these mice. At a cellular level, these compounds achieve this by inhibiting complex I activity in mitochondria, leading to AMP-activated protein kinase activation and subsequent increased glucose uptake by the cells, as measured in the mouse C2C12 muscle cell line. Based on the inhibition of NADH dehydrogenase (IC50 27µmolL(-1)), one of these compounds is close to a thousand fold more potent than metformin. There are no indications of off target effects. The compounds have the potential to have a greater anti-diabetic effect at a lower dose than metformin and may represent a new anti-diabetic compound class. The mechanism of action appears not to be as an insulin sensitizer but rather as an insulin substitute.

Nonadherence and factors affecting adherence of diabetic patients to anti-diabetic medication in Assela General Hospital, Oromia Region, Ethiopia

BACKGROUND

Diabetes mellitus is a major global health problem covering approximately 347 million persons worldwide. Glycemic control has a main role in its management which mainly depends upon patient adherence to the treatment plan. Accurate assessment of medication adherence is necessary for effective management of diabetes.

OBJECTIVE

To assess nonadherence and factors affecting adherence of diabetic patients to anti-diabetic medication in Assela General Hospital (AGH), Oromia Region, Ethiopia.

MATERIALS AND METHODS

A descriptive cross-sectional study was conducted on patients seeking anti-diabetic drug treatment and follow-up at AGH using structured questionnaire and reviewing the patient record card using check list from January 24, 2014 to February 7, 2014. Descriptive analysis was used to describe the percentages and number of distributions of the variables in the study; and association was identified for categorical data. P ≤ 0.05 was considered as statistically significant.

RESULT

Of all respondents, 149 (52.3%) and 136 (47.7%) were female and male, respectively. The majority of the study participants 189 (66.3%) were in the age group of 30-60 years. Two-hundred nineteen (76.8%) of respondents were married currently. The majority, 237 (83.2%) of respondents did not have blood glucose self-monitoring equipment (glucometer). A total of 196 (68.8%) respondents were adhered to anti-diabetic medication. There was a significant association between adherence to the medication and side effect, level of education, monthly income and presence of glucometer at home (P < 0.05).

CONCLUSION

The participants in the area of study were moderately adherent to their anti-diabetic medications with nonadherence rate of 31.2%. Different factors of medication nonadherence were identified such as side effect and complexity of regimen, failure to remember, and sociodemographic factors such as educational level and monthly income.

Long-term safety and efficacy of a novel once-weekly oral trelagliptin as monotherapy or in combination with an existing oral antidiabetic drug in patients with type 2 diabetes mellitus: A 52-week open-label, phase 3 study

Aims/Introduction

Trelagliptin is a novel once‐weekly oral dipeptidyl peptidase‐4 inhibitor for type 2 diabetes mellitus that was first approved in Japan. We evaluated long‐term safety and efficacy of trelagliptin in Japanese patients with type 2 diabetes mellitus.

Materials and Methods

This was a phase 3, multicenter, open‐label study to evaluate long‐term safety and efficacy of trelagliptin. Patients with type 2 diabetes mellitus inadequately controlled despite diet/exercise or treatment with one of the existing oral antidiabetic drugs along with diet/exercise received trelagliptin 100 mg orally once weekly for 52 weeks as monotherapy or combination therapies. The primary end‐points were the safety variables, and the secondary end‐points were glycosylated hemoglobin and fasting plasma glucose.

Results

A total of 680 patients received the following antidiabetic therapies: trelagliptin monotherapy (n = 248), combination with a sulfonylurea (n = 158), a glinide (n = 67), an α‐glucosidase inhibitor (n = 65), a biguanide (n = 70), or a thiazolidinedione (n = 72). During the study, 79.8% of the patients experienced at least one adverse event for monotherapy, 87.3% for combination with a sulfonylurea, 77.6% for a glinide, 81.5% for an α‐glucosidase inhibitor, 64.3% for a biguanide, and 84.7% for a thiazolidinedione, respectively. Most of the adverse events were mild or moderate. The change in glycosylated hemoglobin from baseline at the end of the treatment period was −0.74 to −0.25% for each therapy.

Conclusions

Once‐weekly oral trelagliptin provides well‐tolerated long‐term safety and efficacy in both monotherapy and combination therapies in Japanese patients with type 2 diabetes mellitus.

Adherence to prescribed medications of Iranian traditional medicine in a group of patients with chronic disease

OBJECTIVE

The extent to which a person's health-related behavior corresponds with medical instructions (adherence) is an important modifier of health system effectiveness. This study was designed to determine the patients' adherence to Iranian traditional medicine in a group of patients with chronic disease.

METHODS

Convenience sampling was used to enroll 320 patients with chronic diseases from January 2014 to January 2015 in clinics of traditional medicine affiliated with medical universities in Tehran. Morisky Medication Adherence Scale (MMAS) was used to measure the adherence. After describing the variables and the frequency of adherence, logistic regression analysis was used to determine the influencing factors.

FINDINGS

Mean age was 40.8 (standard deviation [SD] =13) years. The mean of the duration of disease was 54.6 (SD = 56.1) months and mean of the duration of referring to the clinics 6.5 (SD = 6.9) months. Total score of MMAS was zero in 33 (10.3%) of patients (high adherence), one or two in 128 (40%) of patients (moderate adherence), and more than two in 159 (49.7%) of patients (low adherence). Forgetfulness, bad taste, not availability, and the high cost of the drugs were the most commonly reported causes of non-adherence. Adherence was associated with age (odds ratio [OR] =1.05, 95% confidence interval [95% CI] 1-1.1), marriage (OR = 10.8, 95% CI 2.05-57.6), number of prescribed drugs (OR = 0.05, 95% CI 0.02-0.14), and duration of disease (OR = 1.01, 95% CI 1-1.02).

CONCLUSION

Considering the low adherence in users of medications of Iranian traditional medicine, health care practitioners need to be trained in adherence and the influencing factors and also to use some interventions to increase the adherence.

Systematic review of adherence rates by medication class in type 2 diabetes: a study protocol

INTRODUCTION

Treatment options for type 2 diabetes are becoming increasingly complex with people often prescribed multiple medications, and may include both oral and injectable therapies. There is ongoing debate about which drug classes provide the optimum second-line and third-line treatment options. In the real world, patient adherence and persistence determines medication effectiveness. A better understanding of adherence may help inform the choice of second-line and third-line drug classes.

METHODS AND ANALYSIS

This systematic review will compare adherence and persistence rates across the different classes of medication available to people with type 2 diabetes. It will include all identified studies comparing medication adherence or persistence between two or more glucose-lowering medications in people with type 2 diabetes. Research databases (MEDLINE, EMBASE, The Cochrane Library, The Register of Controlled Trials, PsychINFO and CINAHL) will be searched for relevant articles, using a comprehensive search strategy. All identified medication trials and observational studies will be included which compare adherence or persistence across classes of diabetes medication. The characteristics and outcomes of all the included studies will be reported along with a study quality grade, assessed using the Cochrane Risk Assessment Tool. The quality of adjustment for confounders of adherence or persistence will be reported for each study. Where multiple (n ≥ 3) studies provide compare adherence or persistence across the same 2 medication classes, a meta-analysis will be performed.

ETHICS AND DISSEMINATION

No ethics approval is required. This review and meta-analysis (where possible) will provide important information on the relative patient adherence and persistence, with the different classes of diabetes therapies. Once complete, the results will be made available by peer-reviewed publication.

TRIAL REGISTRATION NUMBER

CRD42015027865.

Co-extrusion as a processing technique to manufacture a dual sustained release fixed-dose combination product

OBJECTIVES

This study aimed to design a fixed-dose combination dosage form which provides a sustained release profile for both the freely water-soluble metformin HCl and the poorly soluble gliclazide, two antidiabetic compounds used to treat diabetes mellitus.

METHODS

Hot-melt co-extrusion was used as an innovative manufacturing technique for a pharmaceutical fixed-dose combination product. In this way, a matrix formulation that sustained metformin release could be developed, despite the high drug load in the formulation and the freely soluble nature of the drug.

KEY FINDINGS

It was clear that co-extrusion was perfectly suited to produce a fixed-dose combination product with adequate properties for each of the incorporated APIs. A coat layer, containing at least 30% CAPA(®) 6506 as a hydrophobic polymer, was necessary to adequately sustain the release of the highly dosed freely soluble drug from the 70% metformin HCl-loaded CAPA(®) 6506 core of the co-extrudate. To obtain a complete gliclazide release over 24-h solubilization in Kollidon(®) VA, added as a second polymer to the CAPA(®) 6506 in the coat, was needed.

CONCLUSIONS

Both active pharmaceutical ingredients (APIs), which have different physicochemical characteristics, were formulated in a single dosage form, using co-extrusion.

The value of short- and long-acting glucagon-like peptide-1 agonists in the management of type 2 diabetes mellitus: experience with exenatide

BACKGROUND

Only about half of patients with type 2 diabetes treated with antihyperglycemic drugs achieve glycemic control (HbA1c <7%), most commonly due to poor treatment adherence. Glucagon-like peptide-1 (GLP-1) receptor agonists act on multiple targets involved in glucose homeostasis and have a low risk of causing hypoglycemia. While GLP-1 receptor (GLP-1R) agonists share the same mechanism of action, clinical profiles of individual agents differ, particularly between short- and long-acting agents. In this article, recent findings regarding the pharmacology of GLP-1 agonists are reviewed, and the clinical effects of short- versus long-acting agents are compared.

DATA SOURCES

Relevant articles were identified through a search of PubMed using the keywords glucagon-like peptide-1, GLP-1, glucagon-like peptide-1 receptor agonist, GLP-1R agonist, and exenatide for publications up to 22 May 2015. Supporting data were obtained from additional searches for albiglutide, dulaglutide, liraglutide and lixisenatide as well as from the bibliographies of key articles.

FINDINGS

Short-acting GLP-1R agonists produce greater reductions in postprandial glucose levels by slowing gastric emptying, whereas long-acting GLP-1R agonists produce greater reductions in fasting blood glucose by stimulating insulin secretion from the pancreas. These characteristics can be exploited to provide individualized treatment to patients. A large body of evidence supports the benefits of short- and long-acting exenatide as add-on therapy in patients with inadequate glycemic control despite maximum tolerated doses of metformin and/or sulfonylurea. Exenatide is generally well tolerated and no new safety concerns were identified during long-term follow-up of up to 5 years. A limitation of this review of short-and long-acting GLP-1 receptor agonists is that it focuses on exenatide rather than all the drugs in this class. However, the focus on a single molecule helps to avoid any confusion that may be introduced as a result of differences in molecular structure and size.

CONCLUSIONS

Short-acting GLP-1R agonists including exenatide are well suited to patients with type 2 diabetes with exaggerated postprandial glucose excursions and for co-administration with basal insulin therapy. Long-acting GLP-1R agonists including once weekly exenatide offer greater convenience and are well suited to patients who require specific control of fasting hyperglycemia.

Aspirin in the prevention of cardiovascular events in patients with diabetes

Diabetes imparts a substantial increased risk for cardiovascular disease-related mortality and morbidity. Because of this, current medical guidelines recommend prophylactic treatment with once-daily, low-dose aspirin (acetylsalicylic acid) for primary and secondary prevention of cardiovascular (CV) events in high-risk patients. However, only modest reductions in CV events and mortality have been observed with once-daily aspirin treatment in patients with diabetes, including patients with a previous CV event, perhaps because of disparity between aspirin pharmacokinetics and diabetes-related platelet abnormalities. Once-daily aspirin irreversibly inactivates platelets for only a short duration (acetylsalicylic acid half-life, approximately 15-20 minutes), after which time newly generated, active platelets enter the circulation and weaken aspirin's effect. Platelets from patients with diabetes are more reactive and are turned over more rapidly than platelets from normal individuals; the short inhibitory window provided by once-daily aspirin may therefore be insufficient to provide 24-h protection against CV events. Alternative conventional aspirin regimens (e.g. higher daily dose, twice-daily dosing, combination with clopidogrel) and newer formulations (e.g. 24-h, extended-release) have been proposed to overcome the apparent limited efficacy of conventional aspirin in patients with diabetes; however, tolerability concerns and limited clinical efficacy data need to be taken into account when considering the use of such regimens.

First novel once-weekly DPP-4 inhibitor, trelagliptin, for the treatment of type 2 diabetes mellitus

INTRODUCTION

Dipeptidyl peptidase-4 (DPP-4) inhibitors are weight neutral and well tolerated, and provide better glycaemic control for a longer period compared to conventional therapies. Despite the fact that various drugs are available, glycaemic control remains suboptimal in approximately half of patients with type 2 diabetes mellitus; one of the major reasons for low medication adherence.

AREAS COVERED

A novel DPP-4 inhibitor, trelagliptin, was approved in Japan in March 2015, and is the first once-weekly oral antidiabetic agent in the world. In this review, current issues concerning medication adherence for the treatment of diabetes are discussed followed by a summary of the characteristics and future expectations of trelagliptin, by reviewing the recent phase I, II, and III clinical studies of trelagliptin.

EXPERT OPINION

Trelagliptin has demonstrated superiority to placebo and non-inferiority to alogliptin, indicating its efficacy and tolerance in Japanese patients. Trelagliptin is expected to improve adherence and prevent complications. Due to the convenient dosing regimen, it is expected to be widely used in the clinical setting. A large-scale long-term study will help further confirm its long-term efficacy and safety, patients' satisfaction, and medication adherence.

Determinants of adherence to diabetes treatment

BACKGROUND

Understanding and improving medication adherence is crucial in diabetes management. Adherence to a diabetes regimen can improve glucose control and limit the development of complications. The aim of the present study was to evaluate the extent to which a variety of factors influence diabetes medication adherence.

METHODS

A medication adherence survey was made available on WebMD, a medical information website for patients and/or consumers. Respondents were residents of the US, ≥18 years old, and diagnosed with either type 1 or type 2 diabetes mellitus (self-reported).

RESULTS

Behavioral adherence (self-reported doses missed per week) correlated with perceived adherence (patients' self-report of their overall impression of medication adherence, ranked 0-5; P < 0.001). Adherent patients (very few [0%-10%] issues with adherence) were more likely to report having received information from their physician. Mostly adherent patients (few [11%-26%] issues with adherence) were less likely to obtain information from their physician, but reported more medication self-titration. Somewhat non-adherent patients (some [27%-46%] adherence issues) reported more "self-consciousness factors" and hypoglycemia. Non-adherent patients (many [47%-88%] adherence issues) were more likely to report worries about medication side effects.

CONCLUSIONS

Receiving information from a healthcare provider is associated with greater diabetes medication adherence, suggesting the importance of clinicians making time to provide patient education.

Factors associated with adherence to oral antihyperglycemic monotherapy in patients with type 2 diabetes mellitus in the United Kingdom

To evaluate adherence to oral antihyperglycemic monotherapy, we conducted a retrospective cohort study of a UK clinical database. The mean proportion of days covered was 73.5%, and 60.1% of patients were adherent. Younger age and fewer concomitant medications were negatively associated with the likelihood of being adherent.

Adherence to diabetes medication: a systematic review

AIMS

To investigate the extent of and factors associated with adherence to Type 2 diabetes medication.

METHODS

The CINAHL, Embase, International Pharmaceutical Abstracts, Medline, PubMed and PsychINFO databases were searched for the period January 2004 to July 2013. Papers were included in the present review if they reported the prevalence of adherence (the percentage of the study population that is classified as adherent) to Type 2 diabetes medication and used validated adherence measures with a defined cut-off point to indicate adherence. Reported factors were classified as potential predictors if the studies that examined that particular variable reported consistent findings.

RESULTS

Of the 27 studies included in the present review, the prevalence of adherence ranged from 38.5 to 93.1%. Only six out of 27 studies (22.2%) reported prevalence of adherence of ≥ 80% among their study population. Depression and medication cost were found to be consistent and potentially modifiable predictors for diabetes medication-taking behaviour. The associations between adherence and other factors were inconsistent among the reviewed studies.

CONCLUSIONS

Adherence to diabetes medication remains an ongoing problem. This review has highlighted the urgent need to develop consensus about what constitutes good adherence in diabetes. Further research is needed to clarify modifiable factors, in addition to depression and medication cost, that influence adherence and may provide a focus for targeted interventions to promote adherence, optimize diabetes control and limit the progression of diabetes.

Single-pill combination therapy for type 2 diabetes mellitus: linagliptin plus empagliflozin

BACKGROUND

Treatment of type 2 diabetes mellitus invariably requires the use of multiple daily medications which can impact negatively on patient adherence. As a result, there is growing interest in the use of single-pill combinations that can reduce the pill burden. Many such formulations incorporate metformin, although this agent is not suitable for all patients. The single-pill combination of the dipeptidyl peptidase-4 inhibitor linagliptin with the sodium glucose co-transporter 2 inhibitor empagliflozin offers a new and attractive option, given their complementary mechanisms of action.

SCOPE

Publications with titles containing the keywords 'linagliptin' or 'empagliflozin' were identified from a non-systematic search of PubMed without date restrictions, together with abstracts presented at the annual meetings of the American Diabetes Association and the European Association for the Study of Diabetes 2012-2014. ClinicalTrials.gov was searched for entries containing these two keywords. Additional references known to the author were included.

FINDINGS

The efficacy and safety of linagliptin and empagliflozin as monotherapy or in combination with other oral antidiabetic drugs has been established through extensive clinical trial programs. Studies specifically evaluating the efficacy/safety of a dipeptidyl peptidase-4 inhibitor/sodium glucose co-transporter 2 inhibitor in combination are limited, but do include two studies of linagliptin/empagliflozin of up to 52 weeks in duration. These studies show that the single-pill combination of linagliptin and empagliflozin produced clinical improvements in glycemic control that were generally superior to the improvements seen with linagliptin and empagliflozin alone, but with a safety profile comparable to that of the individual constituents.

CONCLUSIONS

The single-pill combination of linagliptin and empagliflozin, with their complementary mechanisms of action, is a promising treatment option for patients with type 2 diabetes mellitus. It would reduce the daily pill burden in this population, potentially improving adherence to, and optimizing the benefits of, treatment of diabetes mellitus.

The Malaysian Medication Adherence Scale (MALMAS): Concurrent Validity Using a Clinical Measure among People with Type 2 Diabetes in Malaysia

Medication non-adherence is a prevalent problem worldwide but up to today, no gold standard is available to assess such behavior. This study was to evaluate the psychometric properties, particularly the concurrent validity of the English version of the Malaysian Medication Adherence Scale (MALMAS) among people with type 2 diabetes in Malaysia. Individuals with type 2 diabetes, aged 21 years and above, using at least one anti-diabetes agent and could communicate in English were recruited. The MALMAS was compared with the 8-item Morisky Medication Adherence Scale (MMAS-8) to assess its convergent validity while concurrent validity was evaluated based on the levels of glycated hemoglobin (HbA1C). Participants answered the MALMAS twice: at baseline and 4 weeks later. The study involved 136 participants. The MALMAS achieved acceptable internal consistency (Cronbach’s alpha=0.565) and stable reliability as the test-retest scores showed fair correlation (Spearman’s rho=0.412). The MALMAS has good correlation with the MMAS-8 (Spearman’s rho=0.715). Participants who were adherent to their anti-diabetes medications had significantly lower median HbA1C values than those who were non-adherence (7.90 versus 8.55%, p=0.032). The odds of participants who were adherent to their medications achieving good glycemic control was 3.36 times (95% confidence interval: 1.09-10.37) of those who were non-adherence. This confirms the concurrent validity of the MALMAS. The sensitivity of the MALMAS was 88.9% while its specificity was 29.6%. The findings of this study further substantiates the reliability and validity of the MALMAS, in particular its concurrent validity and sensitivity for assessing medication adherence of people with type 2 diabetes in Malaysia.

Once-weekly trelagliptin versus daily alogliptin in Japanese patients with type 2 diabetes: a randomised, double-blind, phase 3, non-inferiority study

BACKGROUND

Trelagliptin is a novel once-weekly oral DPP-4 inhibitor. We assessed the efficacy and safety of trelagliptin versus the daily oral DPP-4 inhibitor alogliptin in Japanese patients with type 2 diabetes.

METHODS

We did a randomised, double-blind, active-controlled, parallel-group, phase 3, non-inferiority study at 26 sites in Japan. We included individuals with type 2 diabetes inadequately controlled by diet and exercise. We randomly assigned patients (2:2:1) to receive trelagliptin (100 mg) once per week, alogliptin (25 mg) once per day, or placebo for 24 weeks. Randomisation was done electronically and independently from the study with permuted blocks of ten patients. Patients and clinicians were masked to group assignment. Patients in the trelagliptin group were given trelagliptin once a week and oral alogliptin placebo every day, whereas patients in the alogliptin group were given oral trelagliptin placebo once a week and oral alogliptin every day (double-dummy design). Patients in the placebo group were given an oral alogliptin placebo once a day and an oral trelagliptin placebo once a week. Our primary outcome was between-groups difference in change in HbA1c concentration from baseline to the end of treatment. The non-inferiority margin was 0·4%. Our analysis included all patients who were randomised and received at least one dose of study drug. The study is registered with ClinicalTrials.gov, number NCT01632007.

FINDINGS

Between May 26, 2012, and Nov 20, 2012, we enrolled 357 patients. 243 patients were included in the analysis (101 for trelagliptin, 92 for alogliptin, and 50 for placebo). In the primary analysis, the least squares mean change in HbA1c concentration was -0·33% in the trelagliptin group (SE 0·059) and -0·45% in the alogliptin group (0·061) based on the ANCOVA model. The least squares mean difference (trelagliptin minus alogliptin) of change from baseline in HbA1c concentration was 0·11% (95% CI -0·054 to 0·281). Trelagliptin was non-inferior to alogliptin. Both active groups had significantly reduced mean HbA1c concentrations at end of treatment compared with placebo (p<0·0001). The frequency of adverse events was similar between groups. No hypoglycaemia was reported with trelagliptin and the drug was well tolerated.

INTERPRETATION

The once-weekly DPP-4 inhibitor trelagliptin showed similar efficacy and safety to alogliptin once daily in Japanese patients with type 2 diabetes. Trelagliptin could be a useful new antidiabetes drug that needs to be given once a week.

FUNDING

Takeda Pharmaceutical Company.

Usability and training differences between two personal insulin pumps

The purpose of this study was to determine if there were usability and training differences between the Medtronic MiniMed Paradigm Revel Insulin Pump and the Tandem Diabetes Care t:slim Insulin Pump during use by representative users, performing representative tasks, in a simulated use environment. This study utilized a between-subjects experimental design with a total of 72 participants from 5 sites across the United States. Study participants were randomized to either the Revel pump group or the t:slim Pump group. Participants were 18 years of age or older and managed their diabetes using multiple daily insulin injections. Dependent variables included training time, training satisfaction, time on task, task failures, System Usability Scale (SUS) ratings, perceived task difficulty, and a pump survey that measured different aspects of the pumps and training sessions. There was a statistically significant difference in training times and error rates between the t:slim and Revel groups. The training time difference represented a 27% reduction in time to train on the t:slim versus the Revel pump. There was a 65% reduction in participants' use error rates between the t:slim and the Revel group. The t:slim Pump had statistically significant training and usability advantages over the Revel pump. The reduction in training time may have been a result of an optimized information architecture, an intuitive navigational layout, and an easy-to-read screen. The reduction in use errors with the t:slim may have been a result of dynamic error handling and active confirmation screens, which may have prevented programming errors.

Patterns and obstacles to oral antidiabetic medications adherence among type 2 diabetics in Ismailia, Egypt: a cross section study

Introduction

Diabetes is a costly and increasingly common chronic disease. Effective management of diabetes to achieve glycemic control improves patient quality of life. Adherence rates to drug regimens in patients with type 2 diabetes are relatively low and vary widely between populations. There are many factors that could affect patient adherence to drug therapy. The aim of the present study was assessing patterns and obstacles to adherence of type 2 diabetic patients to their oral hypoglycemic drugs.

Methods

The present work is a descriptive cross section study, carried on type 2 diabetic patients who were on oral hypoglycemic drugs. Data concerning adherence to drugs was assessed using measure treatment adherence scale (MTA).

Results

A total of 372 (55.59% males and 44.41% females) patients with type-2 diabetes fulfilled the inclusion criteria and included in the study. Among the participants, 26.1% were found to have good adherence, 47.9% had a fair adherence, and 26% had poor adherence.

Conclusion

The overall rate of medication adherence among the diabetic patients population was suboptimal and non-acceptable. Evaluation of adherence is vital for patients with diabetes in order to determine factors and barriers affecting the adherence and to manage them.

Factors associated with adherence to oral antihyperglycemic monotherapy in patients with type 2 diabetes

AIM

To estimate the rate of adherence to oral antihyperglycemic monotherapy for patients with type 2 diabetes in the US and describe factors associated with adherence in these patients.

MATERIALS AND METHODS

In this retrospective cohort analysis, patients aged 18 years or older with a type 2 diabetes diagnosis received between 1 January 2007 and 31 March 2010 were identified using a large US-based health care claims database. The index date was defined as the date of the first prescription for oral antihyperglycemic monotherapy during this period. Patients had to have continuous enrollment in the claims database for 12 months before and after the index date. Adherence was assessed using proportion of days covered (PDC) and an adjusted logistic regression analysis was performed to evaluate factors associated with adherence (PDC ≥80%).

RESULTS

Of the 133,449 eligible patients, the mean age was 61 years and 51% were men. Mean PDC was 75% and the proportion of patients adherent to oral antihyperglycemic monotherapy was 59%. Both mean PDC and PDC ≥80% increased with increasing age and the number of concomitant medications, and were slightly higher in men compared to women. Results from the logistic regression demonstrate an increased likelihood of non-adherence for patients who were younger, new to therapy, on a twice-daily dose, female, or on fewer than three concomitant medications compared to their reference groups. Higher average daily out-of-pocket pharmacy expense was also associated with an increased likelihood of non-adherence. All results were statistically significant (P<0.05).

CONCLUSION

Patient characteristics, treatment regimens, and out-of-pocket expenses were associated with adherence to oral antihyperglycemic monotherapy in our study.

Factors associated with medication information in diabetes care: differences in perceptions between patients and health care professionals

PURPOSE

This qualitative study in patients with type 2 diabetes and health care professionals (HCPs) aimed to investigate which factors they perceive to enhance or impede medication information provision in primary care. Similarities and differences in perspectives were explored.

METHODS

Eight semistructured focus groups were conducted, four with type 2 diabetes patients (n=25) and four with both general practitioners (n=13) and health care assistants (n=10). Sessions were audio and video recorded, transcribed verbatim, and subjected to computer-aided qualitative content analysis.

RESULTS

Diabetes patients and HCPs broadly highlighted similar factors as enablers for satisfactory medication information delivery. Perceptions substantially differed regarding impeding factors. Both patients and HCPs perceived it to be essential to deliver tailored information, to have a trustful and continuous patient-provider relationship, to regularly reconcile medications, and to provide tools for medication management. However, substantial differences in perceptions related to impeding factors included the causes of inadequate information, the detail required for risk-related information, and barriers to medication reconciliation. Medication self-management was a prevalent topic among patients, whereas HCPs' focus was on fulfilling therapy and medication management responsibilities.

CONCLUSION

The findings suggest a noteworthy gap in perceptions between information provision and patients' needs regarding medication-related communication. Medication safety and adherence may be improved if HCPs collaborate more closely with diabetes patients in managing their medication, in particular by incorporating the patients' perspective. Health care systems need to be structured in a way that supports this process.

Meta-analysis of studies examining medication adherence, persistence, and discontinuation of oral antihyperglycemic agents in type 2 diabetes

OBJECTIVE

To estimate overall rates of adherence, persistence, and discontinuation for patients with type 2 diabetes mellitus (T2DM) prescribed oral antihyperglycemic agents (OAHAs) by combining results of published studies.

RESEARCH DESIGN AND METHODS

A systematic literature review was conducted to identify articles published in English over the last 10 years evaluating the use of OAHAs for the treatment of T2DM. Databases searched included PubMed/MEDLINE, EMBASE, and the Cochrane Library. Seventy studies reporting adherence, persistence or discontinuation were identified by two independent reviewers and 40 reported relevant endpoints for the analysis. Outcomes included: (1) mean adherence defined as the average medication possession ratio (MPR); (2) proportion of adherent patients (MPR ≥ 80%); (3) discontinuation; and (4) persistence. Adherence and persistence were reported in observational studies only. Discontinuation was examined separately in randomized controlled trials (RCTs) and observational studies. Meta-analyses were conducted using both fixed and random effects models. When meta-analysis was not appropriate for a given outcome, descriptive statistics were provided.

RESULTS

The pooled mean MPR (95% confidence interval [CI]) was 75.3% (68.8%-81.7%; n = 13) and the proportion of adherent patients (95% CI) was 67.9% (59.6%-76.3%; n = 12). The discontinuation rate (95% CI) in RCTs was 31.8% (17.0%-46.7%; n = 7). Persistence and discontinuation were not assessed via meta-analysis for observational studies due to the limited number of available studies and differences in outcome definitions. In these studies, persistence estimates ranged from 41.0% to 81.1%, with a mean (95% CI) of 56.2% (46.1%-66.3%; n = 6), while discontinuation estimates ranged from 9.9% to 60.1%, with a mean (95% CI) of 31.4% (17.6%-45.3%; n = 6).

LIMITATIONS

Limitations include (1) the use of MPR as a proxy for adherence, (2) limited number of studies available, and (3) observed heterogeneity.

CONCLUSION

The results of the analysis demonstrate that medication adherence, persistence, and discontinuation rates are suboptimal in patients with T2DM prescribed OAHAs.

Level of sustained glycemic control and associated factors among patients with diabetes mellitus in Ethiopia: a hospital-based cross-sectional study

BACKGROUND

The level of sustained glycemic control in patients with diabetes mellitus (DM) is a major determinant of the occurrence of both acute and chronic complications. However, information about the level of glycemic control among patients in the follow-up care at the University of Gondar Referral Hospital is scanty. The study assessed the degree of glycemic control and associated factors among diabetic patients in the study area.

METHOD

A hospital-based cross-sectional study was conducted at the University of Gondar Referral Hospital. All diabetic patients aged ≥18 years who visited the Diabetes Clinic in January and February 2013 for follow-up medical evaluation and medication participated in the study. Patients with glycosylated hemoglobin test (HbA1c) of ≥7% were classified as having a poor level of glycemic control. Propensity score was used to estimate the treatment effect. Multivariable logistic regression analysis was applied to determine the associated factors.

RESULT

Two hundred and fifty three (64.7%) of the 391 diabetic patients included in the study had a poor level of glycemic control, as evidenced by HbA1c ≥7%. Poor glycemic control was much higher among Type 1 patients (82.9%) compared with Type 2 patients (57.5%). Being on insulin treatment (AOR =2.51; 95% CI =1.25, 5.04) and reporting poor medication adherence (AOR =3.19; 95% CI =1.76, 5.80) were found to be associated with poor glycemic control among Type 2 DM patients. High waist circumference was inversely associated with a poor level of glycemic control in Type 1 DM patients (AOR =0.05; 95% CI =0.01, 0.85).

CONCLUSION

The proportion of diabetic patients with a poor level of glycemic control is high. We recommend a comprehensive intervention to improve the overall treatment adherence with special attention to DM patients receiving insulin.

Medication burden in the first 5 years following diagnosis of type 2 diabetes: findings from the ADDITION-UK trial cohort

INTRODUCTION

Individuals with screen-detected diabetes are likely to receive intensified pharmacotherapy to improve glycaemic control and general cardiometabolic health. Individuals are often asymptomatic, and little is known about the degree to which polypharmacy is present both before, and after diagnosis. We aimed to describe and characterize the pharmacotherapy burden of individuals with screen-detected diabetes at diagnosis, 1 and 5 years post-diagnosis.

METHODS

The prescription histories of 1026 individuals with screen-detected diabetes enrolled in the ADDITION-UK trial of the promotion of intensive treatment were coded into general medication types at diagnosis, 1 and 5 years post-diagnosis. The association between change in the count of several medication types and age, baseline 10-year UK Prospective Diabetes Study (UKPDS) cardiovascular disease (CVD risk), sex, intensive treatment group and number of medications was explored.

RESULTS

Just under half of individuals were on drugs unrelated to cardioprotection before diagnosis (42%), and this increased along with a rise in the number of prescribed diabetes-related and cardioprotective drugs. The medication profile over the first 5 years suggests multimorbidity and polypharmacy is present in individuals with screen-detected diabetes. Higher modeled CVD risk at baseline was associated with a greater increase in cardioprotective and diabetes-related medication, but not an increase in other medications.

CONCLUSION

As recommended in national guidelines, our results suggest that treatment of diabetes was influenced by the underlying risk of CVD. While many individuals did not start glucose lowering and cardioprotective therapies in the first 5 years after diagnosis, more information is required to understand whether this represents unmet need, or patient-centered care.

TRIAL REGISTRATION NUMBER

CNT00237549.

What factors influence concordance with medications? Findings from the U.K. Asian Diabetes study

AIMS

To investigate concordance with medication, as assessed at baseline and at 1- and 2-year follow-up, and to examine factors associated with non-concordance in a UK-resident South-Asian population.

METHODS

Data from the UK Asian Diabetes Study were analysed. Concordance with medications was assessed and recorded at three time points during the study. Multiple logistic regression was used to investigate the factors associated with non-concordance; the associations of baseline factors with year 1 concordance and baseline plus year 1 factors with year 2 concordance.

RESULTS

Data for 403 patients from seven practices participating in the UK Asian Diabetes Study were analysed. The numbers of patients who were non-concordant were: 63 (16%) at baseline; 101 (25%) at year 1; and 122 (30%) at year 2. The baseline-measured variables that were significantly associated with year 1 non-concordance included diabetes duration, history of cardiovascular disease, components of the EuroQol quality of life questionnaire, the EQ-5D score, and number of medications prescribed. In multivariable analyses, the most important determinant of year 1 non-concordance was baseline non-concordance: odds ratio 13.6 (95% confidence limits 4.7, 39.9). Number of medications prescribed for blood pressure control was also significant: odds ratio 1.8 (95% confidence limits 1.4, 2.4). Similar results were observed for year 2 non-concordance.

CONCLUSIONS

Non-concordance with medications was common and more likely in people prescribed more medications. The current target-driven management of risk factor levels may lead to increasing numbers and doses of medications. Considering the high cost of medications and the implications of poor health behaviours on morbidity and mortality, further investigation of prescribing behaviours and the factors affecting patient concordance are required.

Does convenience matter in health care delivery? A systematic review of convenience-based aspects of process utility

OBJECTIVES

To systematically review the existing literature on the value associated with convenience in health care delivery, independent of health outcomes, and to try to estimate the likely magnitude of any value found.

METHODS

A systematic search was conducted for previously published studies that reported preferences for convenience-related aspects of health care delivery in a manner that was consistent with either cost-utility analysis or cost-benefit analysis. Data were analyzed in terms of the methodologies used, the aspects of convenience considered, and the values reported.

RESULTS

Literature searches generated 4715 records. Following a review of abstracts or full-text articles, 27 were selected for inclusion. Twenty-six studies reported some evidence of convenience-related process utility, in the form of either a positive utility or a positive willingness to pay. The aspects of convenience valued most often were mode of administration (n = 11) and location of treatment (n = 6). The most common valuation methodology was a discrete-choice experiment containing a cost component (n = 15).

CONCLUSIONS

A preference for convenience-related process utility exists, independent of health outcomes. Given the diverse methodologies used to calculate it, and the range of aspects being valued, however, it is difficult to assess how large such a preference might be, or how it may be effectively incorporated into an economic evaluation. Increased consistency in reporting these preferences is required to assess these issues more accurately.

Defining the role of medication adherence in poor glycemic control among a general adult population with diabetes

Aims

This study assesses the attributable impact of adherence to oral glucose medications as a risk factor for poor glycemic control in population subgroups of a large general population, using an objective medication adherence measure.

Methods

Using electronic health records data, adherence to diabetes medications over a two-year period was calculated by prescription-based Medication Possession Ratios for adults with diabetes diagnosed before January 1, 2010. Glycemic control was determined by the HbA1c test closest to the last drug prescription during 2010–2012. Poor control was defined as HbA1c>75 mmol/mol (9.0%). Medication adherence was categorized as “good” (>80%), “moderate” (50–80%), or “poor” (<50%). Logistic regression models assessed the role medication adherence plays in the association between disease duration, age, and poor glycemic control. We calculated the change in the attributable fraction of glucose control if the non-adherent diabetic medication population would become adherent by age-groups.

Results

Among 228,846 diabetes patients treated by oral antiglycemic medication, 46.4% had good, 28.8% had moderate, and 24.8% had poor adherence. Good adherence rates increased with increasing disease duration, while glycemic control became worse. There was a strong inverse association between adherence level and poor control (OR = 2.50; CI = 2.43–2.58), and adherence was a significant mediator between age and poor control.

Conclusions

A large portion of the diabetes population is reported to have poor adherence to oral diabetes medications, which is strongly associated with poor glycemic control in all disease durations. While poor adherence does not mediate the poorer glycemic control seen in patients with longer-standing disease, it is a significant mediator of poor glycemic control among younger diabetes patients. A greater fraction of poorly controlled younger patients, compared to older patients, could be prevented if at least 80% adherence to their medications was achieved. Therefore, our results suggest that interventions to improve adherence should focus on this younger sub-group.

Polypharmacy in people with Type 1 and Type 2 diabetes is justified by current guidelines--a comprehensive assessment of drug prescriptions in patients needing inpatient treatment for diabetes-associated problems

AIMS

Our aim was to assess the number of medications prescribed to people with Type 1 or Type 2 diabetes mellitus and to compare these to recommendations by guidelines.

PATIENTS AND METHODS

Data from 155 and 154 people with Type 1 and Type 2 diabetes, respectively, were analysed. Prescribed medications (glucose-lowering drugs, blood pressure medications, drugs to treat cardiovascular risk or diseases, etc.) were counted as compounds per day, tablets per day, injections per day, or other modes of administration.

RESULTS

People with Type 2 diabetes were prescribed 8.4 ± 3.0 different drug compounds per day (maximum, 16), 8.6 ± 3.9 tablets per day (maximum, 22), 2.6 ± 1.6 injections per day (maximum, 7), in total 11.6 ± 4.5 doses of any medication per day (maximum, 27). The numbers for people with Type 1 diabetes were 5.5 ± 3.4 compounds per day (maximum, 15), 4.5 ± 4.3 tablets per day (maximum, 18), 3.9 ± 2.2 injections per day (maximum, 8), in total 8.5 ± 5.1 doses of any medication per day (maximum, 22). Over 97% of the prescriptions corresponded to recommendations by guidelines.

CONCLUSIONS

The number of prescribed drugs is high in people with diabetes mellitus, and higher for those with Type 2 than with Type 1 diabetes. The compatibility of prescriptions with guideline recommendations suggests that even this high number of prescriptions will provide a clinical benefit. The current analysis could provide a basis for a realistic judgement of the burden imposed by polypharmacy in people with diabetes mellitus.

Identifying and meeting the challenges of insulin therapy in type 2 diabetes

Type 2 diabetes mellitus (T2DM) is a chronic illness that requires clinical recognition and treatment of the dual pathophysiologic entities of altered glycemic control and insulin resistance to reduce the risk of long-term micro- and macrovascular complications. Although insulin is one of the most effective and widely used therapeutic options in the management of diabetes, it is used by less than one-half of patients for whom it is recommended. Clinician-, patient-, and health care system-related challenges present numerous obstacles to insulin use in T2DM. Clinicians must remain informed about new insulin products, emerging technologies, and treatment options that have the potential to improve adherence to insulin therapy while optimizing glycemic control and mitigating the risks of therapy. Patient-related challenges may be overcome by actively listening to the patient’s fears and concerns regarding insulin therapy and by educating patients about the importance, rationale, and evolving role of insulin in individualized self-treatment regimens. Enlisting the services of Certified Diabetes Educators and office personnel can help in addressing patient-related challenges. Self-management of diabetes requires improved patient awareness regarding the importance of lifestyle modifications, self-monitoring, and/or continuous glucose monitoring, improved methods of insulin delivery (eg, insulin pens), and the enhanced convenience and safety provided by insulin analogs. Health care system-related challenges may be improved through control of the rising cost of insulin therapy while making it available to patients. To increase the success rate of treatment of T2DM, the 2012 position statement from the American Diabetes Association and the European Association for the Study of Diabetes focused on individualized patient care and provided clinicians with general treatment goals, implementation strategies, and tools to evaluate the quality of care.

Barriers to diabetes medication adherence in North West Ethiopia

BACKGROUND

Low adherence to prescribed diabetes medications is one of the major reasons to poor glycemic control in developing countries. Therefore, this study attempted to assess the magnitude of medication adherence and factors associated with it among adult persons with diabetes in northwest Ethiopia.

METHOD

This study utilized a cross sectional study design with internal comparison. The study population was adult persons with diabetes attending the Diabetes Referral Clinic of Gondar University Hospital. Adherence was assessed using the eight-item Morisky Medication Adherence Scale (MMAS-8). In addition laboratory tests and chart reviews were carried out to collect relevant data. Ordinary logistic regression was used to identify factors associated with adherence.

RESULT

A total of 391 patients were studied. Based on the MMAS-8 scale, the self-reported adherence to diabetic medication was low for 25.4% [95% CI: 21, 29] of the patients, medium for 28.7% [95% CI: 24, 33], and high for 45.9% [95% CI: 41, 50] of the patients. The Mean (±SD) of glycosylated hemoglobin for the low adherence group was 8.2% (±2.1). It was 8.1% (±2.0), for the medium, and 7.4% (±1.6) for the high adherence group. In the multivariate analysis poor wealth status (AOR = 1.99; 1.15, 3.43), using traditional treatment (AOR = 2.90; 1.03, 8.15), and service dissatisfaction (AOR = 2.23; 1.04, 4.80) were significantly associated with low adherence to prescribed diabetic medications.

CONCLUSION

Over half of the persons with diabetes did not adhere to medications. Adherence was poor among users of traditional treatment and those dissatisfied with services. Developing a more intensive communication strategies and improving the quality of services could improve the level of adherence.

Adherence to anti-diabetic drugs among patients with Type 2 diabetes mellitus at Muhimbili National Hospital, Dar es Salaam, Tanzania- A cross-sectional study

Introduction

Adherence to diabetes mellitus treatment regimens among Type 2 diabetes patients in Tanzania has not been well documented. This study sought to assess adherence to antidiabetic drugs and associated factors among patients with Type 2 diabetes mellitus.

Methods

A cross-sectional study was conducted among type 2 diabetes mellitus patients who were attending the Diabetic clinic of Muhimbili National hospital between May 2009 and February 2010. Assement ofadherence to antidiabetic medications was based on patients’ self-reported recall of skipped days without taking medications, over the past one week and three months. Data wereentered and analyzed using Statistical Package for Social Sciences (SPSS Inc. Chicago, Illinois version 16). The crude and adjusted odds ratio (COR/ AOR) and 95% Confidence Interval (CI) were performed to determine factors associated with anti-diabetic medications adherence and a p-value of 0.05 or less was considered statistically significant.

Results

Adherence rates to antidiabetic drugs were found to be 60.2% and 71.2% at one week and three months respectively. High cost of medication was significantly associated with anti-diabetic non-adherence. Adherence to anti-diabetic drugs significantly increased with an increase in number of non-diabetic medications.

Conclusion

Adherence to antidiabetic drugs was found to be suboptimal. Patients with other medical conditions in addition to diabetes mellitus are more likely to adhere to anti-diabetic medications. There is a need for the responsible authorities to set policies that subsidize cost of anti-diabetic drugs to improve adherence and reduce associated complications.

A multistate model and an algorithm for measuring long-term adherence to medication: a case of diabetes mellitus type 2

OBJECTIVES

To develop a multistate model and an algorithm for calculating long-term adherence to medication among patients with a chronic disease.

METHODS

We propose definitions of the different states of waiting, persistence, with sufficient supply to implement the prescribed dosing regimen, gaps, nonpersistence, and nonacceptance and an algorithm for transitions between states to describe long-term adherence to medication treatment. The model and algorithm are operationalized for use in a case with a retrospective cohort of patients with type 2 diabetes mellitus, with access to records of prescribed drugs from a Danish diabetes research hospital and records of filled prescriptions at Danish pharmacies from the Danish Health and Medicines Authority.

RESULTS

Calculations of long-term adherence to medication are shown for patients with type 2 diabetes mellitus on metformin and/or simvastatin. The study shows how the prevalence of patients waiting to initiate treatment, patients with supply to implement the prescribed dosing regimen, patients not accepting treatment, and patients discontinuing treatment varies over time.

CONCLUSIONS

The proposed multistate model and algorithm can easily be translated and used for the calculation of adherence to medication in any chronic disease. The model and algorithm take time into account, and thus, changes in incidence rates and prevalence of the different states over time can be estimated on several time scales (calendar time, age of the patient, and time since indication for medication).

A randomized controlled trial of the efficacy and safety of twice-daily saxagliptin plus metformin combination therapy in patients with type 2 diabetes and inadequate glycemic control on metformin monotherapy

BACKGROUND

To compare the safety and efficacy of saxagliptin 2.5 mg twice daily (BID) versus placebo add-on therapy to metformin immediate release (IR) in patients with type 2 diabetes and inadequate glycemic control with metformin alone.

METHODS

This multicenter, 12-week, double-blind, parallel-group trial enrolled adult outpatients with type 2 diabetes (glycated hemoglobin [HbA1c] 7.0%-10.0%) on stable metformin IR monotherapy (≥1500 mg, BID for ≥8 weeks). Patients were randomized to double-blind saxagliptin 2.5 mg BID or placebo added on to metformin IR following a 2-week, single-blind, placebo add-on therapy lead-in period. The primary end point was the change from baseline to week 12 in HbA1c. Key secondary end points included change from baseline to week 12 in fasting plasma glucose (FPG) and the proportion of patients achieving HbA1c <7.0% or HbA1c ≤ 6.5% at week 12. Efficacy was analyzed in all patients who received randomized study drug with ≥1 postbaseline assessment. Safety was assessed in all treated patients.

RESULTS

In total, 74 patients were randomized to double-blind saxagliptin add-on therapy and 86 to placebo add-on therapy. At week 12, least-squares mean changes (95% CI) from baseline HbA1c (adjusted for baseline HbA1c) were significantly greater (P = 0.006) in the saxagliptin + metformin group -0.56% (-0.74% to -0.38%) versus the placebo + metformin group -0.22% (-0.39% to -0.06%). Adjusted mean changes from baseline in FPG were numerically greater with saxagliptin versus placebo; the difference (95% CI) -9.5 mg/dL (-21.7 to 2.7) was not statistically significant (P = 0.12). A numerically greater proportion of patients in the saxagliptin group than the placebo group achieved HbA1c < 7.0% (37.5% vs 24.2%) or HbA1c ≤6.5% (24.6% vs 10.7%). There were no unexpected safety findings. Hypoglycemia occurred in 4 patients (5.4%) in the saxagliptin group and 1 patient (1.2%) in the placebo group; confirmed hypoglycemia (symptoms plus fingerstick glucose ≤50 mg/dL) occurred in 1 patient in the placebo group.

CONCLUSIONS

Addition of saxagliptin 2.5 mg BID to metformin therapy in patients with type 2 diabetes and inadequate glycemic control on metformin monotherapy reduced HbA1c compared with placebo added to metformin, with an adverse events profile similar to placebo and no unexpected safety findings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00885378.

Medication adherence part two: predictors of nonadherence and adherence

PURPOSE

This is the second of a three-part series on medication adherence in which the authors describe the continuum of adherence to nonadherence of medication usage.

DATA SOURCES

Research articles through MEDLINE and PubMed.

CONCLUSIONS

Understanding the magnitude and scope of the problem of medication nonadherence is the first step in reaching better adherence rates (described in Part One of this series). The second step is to recognize the complexities of the reasons for medication adherence/nonadherence (described here). Reasons for nonadherence include beliefs related to the benefits of medication for physical and mental disorders, complexities of systems of health care and treatment plans, and lifestyle and demographic characteristics of patients. The final step is to evaluate each patient for medication adherence, tailoring the plan of care according to patient and system specific barriers (described in Part Three of this series).

IMPLICATIONS FOR PRACTICE

Nurse practitioners must recognize a critical element of thorough care is to assess medication adherence at each patient visit, countering patient and system barriers as indicated. Nurse practitioners also need to adjust assessment and prescribing practices according to the evidence for best practices to improve medication adherence.

Clinical and economic outcomes in medication-adherent and -nonadherent patients with type 2 diabetes mellitus in the Republic of Korea

BACKGROUND

The prevalence and social burden of type 2 diabetes mellitus (T2DM) is increasing. Medication adherence is necessary for positive outcomes in patients with T2DM.

OBJECTIVE

This study evaluated the association between medication adherence and clinical/economic outcomes in patients with T2DM in the Republic of Korea over a 3-year period.

METHODS

This study used data from the Korean National Diabetes Program at 5 hospitals. Medication possession ratios of ≥90% and <90% were used to define adherent and nonadherent groups, respectively. The degree of glycemic control, changes in blood pressure and lipid profiles, and health care costs were compared.

RESULTS

Of the 608 patients, 472 were medication adherent and 136 were nonadherent. The adherent patients displayed improved fasting blood glucose and hemoglobin A1c during the study. Diastolic blood pressure and total cholesterol were lower at 36 months, and lower low-density lipoprotein cholesterol was noted at baseline and 24 months. The total health care costs were $1861, $2060, and $1924, respectively, versus $1617, $1751, and $1602 during the 3-year study period for the adherent group versus the nonadherent group, respectively (P = 0.316, 0.627, and 0.172, respectively), whereas the outpatient drug costs were $1143, $1176, and $1162 in the adherent group versus $925, $778, and $914 in the nonadherent group (P = 0.002, P < 0.001, and P = 0.001).

CONCLUSIONS

The adherent patients displayed better glycemic control and lipid profiles. Medication-related expenses were higher in the adherent group, but overall health care costs, including hospitalization costs, were similar between the 2 groups.

A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes

OBJECTIVE

To test cognitive behavioral therapy for adherence and depression (CBT-AD) in type 2 diabetes. We hypothesized that CBT-AD would improve adherence; depression; and, secondarily, hemoglobin A1c (A1C).

RESEARCH DESIGN AND METHODS

Eighty-seven adults with unipolar depression and uncontrolled type 2 diabetes received enhanced treatment as usual (ETAU), including medication adherence, self-monitoring of blood glucose (SMBG), and lifestyle counseling; a provider letter documented psychiatric diagnoses. Those randomized to the intervention arm also received 9-11 sessions of CBT-AD.

RESULTS

Immediately after acute treatment (4 months), adjusting for baseline, CBT-AD had 20.7 percentage points greater oral medication adherence on electronic pill cap (95% CI -31.14 to -10.22, P = 0.000); 30.2 percentage points greater SMBG adherence through glucometer downloads (95% CI -42.95 to -17.37, P = 0.000); 6.44 points lower depression scores on the Montgomery-Asberg Depression Rating Scale (95% CI 2.33-10.56, P = 0.002); 0.74 points lower on the Clinical Global Impression (95% CI 0.16-1.32, P = 0.01); and 0.72 units lower A1C (95% CI 0.29-1.15, P = 0.001) relative to ETAU. Analyses of 4-, 8-, and 12-month follow-up time points indicated that CBT-AD maintained 24.3 percentage points higher medication adherence (95% CI -38.2 to -10.3, P = 0.001); 16.9 percentage points greater SMBG adherence (95% CI -33.3 to -0.5, P = 0.043); and 0.63 units lower A1C (95% CI 0.06-1.2, P = 0.03) after acute treatment ended. For depression, there was some evidence of continued improvement posttreatment, but no between-group differences.

CONCLUSIONS

CBT-AD is an effective intervention for adherence, depression, and glycemic control, with enduring and clinically meaningful benefits for diabetes self-management and glycemic control in adults with type 2 diabetes and depression.

An evaluation of patients' adherence with hypoglycemic medications among Papua New Guineans with type 2 diabetes: influencing factors

PURPOSE

The aims of this study were to evaluate the extent of adherence to hypoglycemic medications, assess the relationship between adherence and glycemic control, and evaluate factors affecting adherence.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study of patients with established type 2 diabetes attending the Port Moresby General Hospital Diabetes Clinic. Face-to-face interviews were conducted using a questionnaire designed for the study and data were collected concerning the 3 months prior to interview. The questionnaire covered demographic details, lifestyle, biochemical and physical measurements, and medication management. Glycemic control was investigated among patients adhering to their medications (not missing doses) to different degrees (100%, 95%, 90%, and 80%).

RESULTS

Of a total of 356 participants who were prescribed hypoglycemic medications, 59.6% omitted some of their doses. Age appeared to have a significant impact on adherence at some levels of adherence, with those aged >60 years being more likely to be adherent (logistic regression). Those who were 95%-99% and those who were <80% adherent had a statistically significant risk of a high glycated hemoglobin of >10% (85.5 mmol/mol). Multiple factors were identified as contributors to nonadherence, with patient-based issues (86.0%) and the health care system (21.7%) being the most common.

CONCLUSION

This study showed a significant level of nonadherence among patients with type 2 diabetes in Papua New Guinea. Nonadherence to medication appeared to be associated with poor glycemic control and was due to a variety of reasons. Future interventions aimed at improving adherence will need to take these into account.

Patient adherence issues in the treatment of hepatitis C

The current standard-of-care treatments for chronic hepatitis C, based on a bitherapy that combines peginterferon alpha-2a or -2b and ribavirin for all genotypes, and on a triple therapy with the addition of an antiprotease specifically for genotype 1, are associated with a limited adherence that decreases their efficacy. The main factors limiting adherence are difficulties in taking the treatment and side effects that worsen the quality of life of the patients. Programs of therapeutic education are essential to improve adherence, quality of life, likelihood of viral suppression, improvement of liver disease, and decrease of late complications. Therapeutic education should be understood as an acquisition of decisional, technical, and social competency with the purpose of making the patient able to make health choices, realize their own life plans, and use health care resources in the best manner. The patient should be placed in the center of an organization, comprising various care workers who include social service professionals and medical staff. For hepatitis C, therapeutic education may be separated into three phases: a first phase corresponding to the educative diagnosis; a second phase corresponding to support during treatment; and the third phase corresponding to support after treatment. Therapeutic education is performed using various instruments and methods specifically adapted to the needs and expectations of individual patients. Upcoming treatments for hepatitis C, with evidence for high efficacy, few side effects, and shorter duration, will certainly change the landscape of adherence and the management of therapeutic education.

Improving medication adherence among patients with type 2 diabetes

Type 2 diabetes mellitus (T2DM) accounts for the vast majority of diagnosed diabetes cases and is a considerable burden to the US health care system. However, patients with T2DM often fail to adhere to treatment for numerous reasons including concerns about administration, mode, timing, convenience, adverse events, and cost. As the prevalence of T2DM and the complexity of therapeutic regimens increases, the role of pharmacists in educating patients about treatment benefits, administration techniques, dosage flexibility, and avoiding side effects is critical and may optimize care by increasing the likelihood of treatment adherence. In addition, pharmacists are in a unique position to assess which patients are not taking medications as they are prescribed and can therefore determine the most effective methods to promote adherence. This article will examine the causes of nonadherence in T2DM and the integral role that pharmacists can play in improving medication adherence and persistence. Strategies for improving adherence, such as patient education, motivational interviewing, medication therapy management programs, and collaborative management, will also be considered.

Adherence to therapies in patients with type 2 diabetes

Adherence to therapy is defined as the extent to which a person's behavior in taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider. Patients presenting with type 2 diabetes mellitus are initially encouraged to maintain a healthy diet and exercise regimen, followed by early medication that generally includes one or more oral hypoglycemic agents and later may include an injectable treatment. To prevent the complications associated with type 2 diabetes, therapy frequently also includes medications for control of blood pressure, dyslipidemia and other disorders, since patients often have more than three or four chronic conditions. Despite the benefits of therapy, studies have indicated that recommended glycemic goals are achieved by less than 50% of patients, which may be associated with decreased adherence to therapies. As a result, hyperglycemia and long-term complications increase morbidity and premature mortality, and lead to increased costs to health services. Reasons for nonadherence are multifactorial and difficult to identify. They include age, information, perception and duration of disease, complexity of dosing regimen, polytherapy, psychological factors, safety, tolerability and cost. Various measures to increase patient satisfaction and increase adherence in type 2 diabetes have been investigated. These include reducing the complexity of therapy by fixed-dose combination pills and less frequent dosing regimens, using medications that are associated with fewer adverse events (hypoglycemia or weight gain), educational initiatives with improved patient-healthcare provider communication, reminder systems and social support to help reduce costs. In the current narrative review, factors that influence adherence to different therapies for type 2 diabetes are discussed, along with outcomes of poor adherence, the economic impact of nonadherence, and strategies aimed at improving adherence.